Editor's note: This text-based course is a transcript of the webinar, Rehabilitation Strategies For Persons With Dementia And Neuropsychiatric Conditions: What's The Evidence?, presented by Dennis Klima, PT, MS, PhD, GCS, NCS.
*Please also use the handout with this text course to supplement the material.
Learning Outcomes
- As a result of this course, participants will be able to differentiate between four different forms of irreversible dementia.
- As a result of this course, participants will be able to compare and contrast rehabilitation strategies for patients with delirium, chronic dementia, and reversible dementia.
- As a result of this course, participants will be able to identify evidence-based rehabilitation approaches for patients with dementia, schizophrenia, and functional movement disorder.
Introduction and Background
I have been a physical therapist for many years, with extensive experience in rehabilitation and acute care. Additionally, I directed the Physical Therapist Assistant program in Baltimore, Maryland. However, the most rewarding part of my career has been working alongside exceptional rehabilitation teams, particularly occupational therapists and occupational therapy assistants. Together, we significantly impacted the lives of individuals with complex neuropsychiatric conditions, which ultimately inspired me to develop this course.
Though I spend much time teaching at the university, I consider myself a clinician. This course has no external sponsor, and we will not focus on specific products or services. My goal is to help you distinguish between four forms of irreversible dementia, compare rehabilitation strategies for patients with delirium, chronic dementia, and reversible dementia, and identify evidence-based approaches for treating patients with dementia, schizophrenia, and functional movement disorders.
The Complexity of Neuropsychiatric Conditions
In my experience, integrating neuropsychiatric conditions into a patient's overall care plan adds a multifaceted dimension to their medical profile, particularly in how these conditions affect the movement system and overall quality of life. For instance, I encountered a 68-year-old male patient, three days post-right CVA, with a history of hypertension, type 2 diabetes, and depression.
As I reviewed his medical history, I immediately recognized the need to take precautions related to his hypertension, especially considering the impact of beta blockers on his heart rate. Additionally, I was mindful of his diabetes, planning therapy sessions in alignment with his meal times to avoid any potential complications. However, when I noted his comorbidity of depression, I paused to consider how this would influence his rehabilitation process.
I understood that depression could significantly affect his motivation, energy levels, and overall engagement in therapy, ultimately impacting his recovery and quality of life. This realization underscored the importance of integrating the neuropsychiatric disorder into every aspect of his care. By adopting a holistic approach, I aimed to address not only his physical impairments but also his mental and emotional well-being, ensuring that the therapy was tailored to meet his comprehensive needs.
This experience reaffirmed my belief that acknowledging and addressing neuropsychiatric conditions is crucial in delivering effective and compassionate care. It requires a careful balance of managing the physical symptoms while being attuned to the psychological aspects that are equally influential in the patient's rehabilitation journey.
Frameworks for Managing Neuropsychiatric Patients
To begin managing patients with neuropsychiatric conditions, we must reference frameworks that guide our approach to treatment. One of the most foundational is the International Classification of Functioning, Disability, and Health (ICF) model, which has become a cornerstone in many professions, including ours, when addressing conditions such as schizophrenia, bipolar disorder, and functional motor disorders.
The ICF model replaced the older Nagi model, which was heavily focused on negative aspects such as impairments, functional limitations, and disability. The Nagi model, while useful in its time, lacked consideration for key contextual factors like environmental influences and personal attributes—factors that are critical in occupational therapy when designing interventions tailored to each patient's unique situation.
The ICF model shifts our perspective by emphasizing participation rather than disability. It recognizes that a neuropsychiatric condition may lead to changes in body structure and function, such as limited range of motion, abnormal muscle tone, and decreased strength—elements that are fundamental to functional activities. Additionally, the ICF acknowledges the significant impact of impaired mood and cognition, which are often associated with these disorders, on activities of daily living (ADLs) and instrumental activities of daily living (IADLs).
What makes the ICF particularly powerful is its focus on participation—how a patient's condition impacts their ability to engage in community life, family responsibilities, and work. Occupational therapists and occupational therapy assistants are crucial in facilitating patients' return to these participatory roles. It is important to consider and address the contextual factors that influence rehabilitation, such as transportation barriers, the appropriateness of wheelchair design, and the support system available from caregivers and health professionals.
Moreover, personal factors—age, body mass index, education, and profession—must be integrated into our treatment plans to ensure they are fully personalized. By acknowledging and incorporating these elements, we can create comprehensive, patient-centered care plans that address the multifaceted needs of individuals with neuropsychiatric conditions.
Evidence-Based Practice and Levels of Evidence
When discussing Sackett's levels of evidence, it's crucial to understand that these levels help us determine how well we can generalize findings to patients with similar diagnoses or situations. The highest levels of evidence, such as a 1a or 1b, typically involve systematic reviews of multiple randomized controlled trials (RCTs). These reviews compile and analyze interventions, like a specific exercise routine for upper extremities, that help us conclude whether the intervention is effective. This type of evidence is highly generalizable and reliable.
As we move down the hierarchy, we encounter studies like 2b, which might involve individual cohort studies or lower-quality RCTs. The quality of these studies can be affected by factors like methodology or the number of participants, leading to less reliable results. Further down, we see case series, which are often used in conditions where it's challenging to gather similar patients for larger studies. While these case series don't allow for broad generalization, they can still offer valuable insights and practical ideas that therapists can apply in their practice.
At the bottom of the hierarchy, we find expert opinion, which some humorously refer to as "what Aunt Martha says." However, expert consensus reports are serious considerations, as they involve experts reviewing all available data for a specific diagnosis and making treatment recommendations. These reports are especially important in fields like occupational therapy, where they often set the stage for the clinical management of complex conditions, such as functional motor disorder.
Neuropsychiatric Diagnoses and the DSM-5
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), is indeed an essential reference for diagnosing a wide range of neuropsychiatric conditions, including depression, schizophrenia, and bipolar disorder. It's the ultimate guide, offering detailed parameters for diagnosis that are crucial in clinical settings. The DSM-5 also includes updated content on bereavement, suicide, and grief disorders, reflecting the evolving understanding of these conditions.
However, it's worth noting that the DSM-5 has faced some criticism, particularly regarding the lowered thresholds for certain diagnoses. This has been a point of debate, especially concerning the number of symptoms required within specific time frames to make a diagnosis. Despite these criticisms, the DSM-5 remains a critical tool, and when used in conjunction with Sackett's levels of evidence and the ICF model, it provides a robust foundation for approaching and treating patients with neuropsychiatric conditions.
Clinical Integration: Managing a Day in the Clinic
Reflecting on my time doing per diem work, I recall one particularly busy day in the outpatient unit that tested my ability to integrate various aspects of patient care. The day started with a patient with dementia who was noted as deconditioned, though there wasn't much detail provided about the dementia itself. Following that, I had a session with a patient recovering from Guillain-Barré syndrome, who also had a history of schizophrenia. It was always rewarding to see progress in such cases, but the added layer of schizophrenia required careful consideration in my approach.
Next, I worked with a patient diagnosed with relapsing-remitting multiple sclerosis. While I had a plan in mind for treating MS, discovering the patient's history of bipolar disorder made me rethink how this comorbidity might impact their treatment and overall well-being.
Later in the morning, I attended an in-service with the rehab team, where a student presented a case on functional movement disorder. This was followed by a short break, and then I transitioned to working with a patient with Parkinson's disease, admitted for deconditioned status, who also had a history of depression. Each session required me to balance the physical and neuropsychiatric elements of care, ensuring I addressed all aspects of the patient's health.
The day ended with a particularly challenging case: a patient with a traumatic brain injury at Rancho Level IV, who was agitated and confused. Managing their agitation while trying to provide effective therapy was a complex task, requiring a lot of patience and adaptability.
This experience underscored the importance of integrating neuropsychiatric considerations into every aspect of treatment, ensuring that each patient's unique medical history informs the care they receive. It was a day that truly exemplified the need for a holistic approach in therapy, one that addresses both the physical and psychological dimensions of health.
Dementia: Classifications and Characteristics
With that in mind, I'm heading off to see my first patient, who has dementia. Dementia is a complex and confusing term due to its many operational definitions. However, if we go back to its Latin root, "demens," we understand that it fundamentally refers to an observable decline in mental abilities. This decline in cognitive function leads to a corresponding physical decline, which is the essence of dementia.
When discussing chronic dementias, it's important to recognize that these conditions are irreversible and will not improve over time. Within this broad category, Alzheimer's disease accounts for the majority of cases—historically around 50%, but recent estimates suggest it might be as high as 60% to 80%, especially when including vascular dementia, which is sometimes referred to as multi-infarct or, in older terms, senile dementia.
The remaining chronic dementia cases are comprised of other types, including Lewy body disorder and frontotemporal dementia. The latter is particularly noteworthy for its significant impact on personality and behavior. It has two main variants: the frontal variant, which primarily affects behavior and personality, and the primary progressive aphasia variant, which leads to difficulties in speaking or understanding language.
Interestingly, frontotemporal dementias often affect a younger demographic, typically between the ages of 45 and 60, which sets them apart from other chronic dementias. Additionally, certain chronic neurological diseases like Parkinson's and Huntington's disease can also have a dementia trajectory, with cognitive changes appearing at different stages of the disease.
As I approach this case, it's clear that these patients' trajectory is not one of recovery. Our role will be to manage the symptoms and provide the best possible quality of life through therapeutic interventions.
Reversible Dementias: Identifying and Addressing Underlying Causes
It's crucial to recognize that not all dementia cases are irreversible. In occupational therapy, identifying any acute changes in a patient's cognition can be pivotal because it might point to a reversible cause, and addressing it can significantly improve the patient's cognitive function and overall health.
One of the most common reversible causes of dementia is polypharmacy, where patients are on multiple medications that begin to affect their cognition. For instance, medications like Elavil, an anticholinergic used to treat depression, can cause sedation and cognitive changes. This highlights the importance of ensuring that patients and caregivers have thorough discussions with pharmacists about how their medication regimen might impact their motor and cognitive functions.
Acute infections are another significant cause of reversible dementia. In older adults, a urinary tract infection, pneumonia, or wound can lead to an elevated white count, fever, and subsequent cognitive changes. Depression can also cause cognitive impairments, leading to what we term pseudodementia—a condition where the cognitive decline is not due to chronic dementia like Alzheimer's or vascular dementia but rather to severe depression.
Another condition I've encountered is liver failure, where cognitive changes occur due to the buildup of toxins in the body. In all these scenarios, it's vital to recognize these symptoms early. As occupational therapy practitioners, you may be the first to notice these changes, making it essential to communicate with the healthcare team to ensure the underlying cause is identified and treated appropriately. This proactive approach can make a significant difference in the patient's recovery and quality of life.
Normal Pressure Hydrocephalus (NPH) and Delirium
Normal pressure hydrocephalus (NPH) is a condition that often comes up in clinical practice, particularly when working with older adults in settings like skilled nursing facilities, rehab, or home health. Despite its name, NPH can involve fluctuating cerebrospinal fluid (CSF) pressure due to a blockage in the CSF clearance system. This blockage can be idiopathic or occur secondary to other neurological conditions like traumatic brain injury, infections such as meningitis or encephalitis, or even tumors like glioblastomas and meningiomas.
The classic triad of symptoms associated with NPH—acute gait deviations, cognitive impairment, and loss of bladder control—was first described by Dr. Salomon Hakim and remains key to diagnosing this condition. Diagnosis typically involves imaging studies such as CT or MRI and thorough cognitive and mobility assessments. A lumbar puncture, where a small amount of CSF is removed, can be used to observe if the patient’s symptoms improve, which helps in deciding if they might benefit from a shunt procedure. This procedure involves inserting a shunt to divert the excess fluid to the abdomen, which can be absorbed into the circulatory system. Another less common option is an endoscopic third ventriculostomy, which creates a new pathway for CSF to bypass blockages.
For therapy practitioners, our role in managing NPH is crucial. We conduct comprehensive cognitive, mobility, and balance assessments before and after a lumbar puncture to provide valuable input for the differential diagnosis. Recognizing the triad of symptoms and understanding the difference between delirium and dementia is also vital. Delirium, unlike dementia, includes lethargy and is usually reversible once the underlying medical condition is treated. Early mobility interventions, especially in ICU settings, have proven effective in preventing or reducing ICU delirium, highlighting the importance of innovative rehabilitation strategies.
These insights emphasize OT and PT's integral role in diagnosing and managing NPH and related conditions, ensuring that we contribute meaningfully to the overall care team.
Alzheimer’s Disease: Pathophysiology and Care Considerations
As I mentioned, the vast majority of irreversible dementia conditions are caused by Alzheimer's disease. This unfortunate disease is a chronic, degenerative condition affecting 11% of U.S. adults over the age of 65 and 32% of those over the age of 85. It’s a condition we frequently encounter in rehabilitation settings. In total, 5.4 million Americans have Alzheimer's, making it the 6th leading cause of death in the United States.
The life expectancy for Alzheimer's patients is generally quoted as eight to eleven years, but this can vary depending on the quality of care and the progression of medical complications. Diagnosis should involve a complete medical assessment by a thorough geriatric team, ideally interdisciplinary, to evaluate medications, orientation, cognition, mobility, and the ability to perform IADLs and ADLs. This is crucial, especially when cognitive changes consistent with irreversible dementia are suspected.
An important statistic is that approximately two-thirds of caregivers are women, and 34% are 65 or older. While our focus in rehabilitation is often on improving the patient’s ADL abilities, balance, and wheelchair seating, caregiver training is equally vital due to the significant burden many of these caregivers face, particularly as many patients are living at home with the disease.
The hallmark feature of Alzheimer's disease is massive brain atrophy, particularly in the cortical and hippocampal regions. We also see amyloid protein plaques on the outside of neurons, which interfere with neuronal transmission, and tau protein tangles inside the neurons, disrupting neuronal metabolism. This double-edged sword of amyloid plaques and neurofibrillary tangles, along with a loss of acetylcholine neurons, interrupts brain circuitry. Additionally, the APOE4 gene is a known genetic risk factor that increases susceptibility to Alzheimer's disease.
When patients first present with cognitive changes, they may have mild cognitive impairment (MCI), characterized by a tendency to forget or mild subjective memory loss. Patients with MCI can generally function normally or relatively normally, scoring between 26 and 30 on the Mini-Mental State Examination (MMSE). However, a portion of these patients may progress to full-blown Alzheimer's disease.
As Alzheimer's progresses, it typically moves through three stages. In the mild stage, patients often score between 20 and 25 on the MMSE, with key features including forgetfulness and repetitive questioning, alongside mild impairments in daily function. In the moderate stage, with MMSE scores generally between 10 and 19, cognitive deficits become more pronounced, with significant word-finding difficulties and inappropriate juxtaposition of words. At this stage, supervision is required for safety, and the ICF contextual factors become crucial for determining who will provide 24/7 care at home. In the severe stage, MMSE scores typically fall into the single digits. Patients may become agitated or, conversely, mute, with significant alterations in sleep patterns and total dependence for ADLs such as dressing, feeding, and bathing. At this stage, caregiver training becomes particularly important as the patient’s needs increase.
The Nun Study, led by Dr. David Snowden, provided key insights into Alzheimer's disease, including the inverse relationship between educational status and Alzheimer's incidence. The study also found that nuns who expressed positive emotions in their vocational letters tended to live longer. Interestingly, some nuns had significant amyloid and tau pathology in their brains yet remained cognitively intact, suggesting that the location of these pathologic markers is as important as their quantity.
In terms of treatment, cholinesterase inhibitors, such as donepezil (Aricept), are commonly prescribed to prevent the breakdown of acetylcholine, which is important for learning and memory. These medications may delay the worsening of symptoms for six to twelve months in about half of the patients who take them. Memantine (Namenda) is another medication used for moderate to severe Alzheimer's, regulating the glutamate neurotransmitter. However, the efficacy of these medications varies from patient to patient.
A newer medication, Adlhelm, was FDA-approved in 2021 and aims to reduce the amount of amyloid plaques in the brain. However, it has been controversial due to imaging findings that suggest potential side effects, leading to ongoing monitoring of patients on this drug.
Vascular dementia, often referred to as multi-infarct dementia, presents differently, with a stepwise progression due to small or large infarcts in the brain. This condition highlights the importance of brain health initiatives, such as controlling blood pressure, cholesterol, and diabetes, which are hoped to slow down its progression.
Lewy body disease and the overlap with Parkinson’s disease present another challenge, especially with the prominent visual hallucinations and the potential exacerbation of Parkinsonian symptoms due to antipsychotic medications.
Overall, Alzheimer’s disease and other forms of irreversible dementia require a comprehensive approach to rehabilitation, with a focus not only on the patient’s cognitive and functional abilities but also on supporting the caregivers who play a crucial role in managing the disease at home.
Cognitive Assessments for Dementia
Cognitive assessments like the Mini-Mental State Examination (MMSE) and the clock-drawing test are widely used to evaluate cognitive decline in patients with dementia. The MMSE assesses memory, attention, and language, while the clock-drawing test evaluates spatial awareness and executive function. These tools help guide treatment and provide benchmarks for tracking disease progression.
One landmark study on Alzheimer’s disease was the Nun Study, led by Dr. David Snowden. This study found that nuns with higher educational levels were less likely to develop Alzheimer’s disease. The study also showed that positive emotional words in written correspondence were associated with increased longevity, highlighting the potential protective effects of education and positive emotional states against cognitive decline.
Depression and Bipolar Disorder in Rehabilitation
Depression is more than just a bad day—it’s a medical condition that can significantly impact rehabilitation outcomes. Patients with depression often experience slower recovery from conditions like hip fractures and myocardial infarctions. In rehabilitation, tools like the Geriatric Depression Scale (GDS) and the PHQ-9 are used to assess depression.
Bipolar disorder adds a layer of complexity and is characterized by mood swings between mania and depression. Patients with bipolar disorder may be treated with medications like lithium, which requires careful monitoring for toxicity, or with mood stabilizers like Lamictal and Depakote. In OT, we must understand the mood cycles and ensure patients adhere to their medication regimens while incorporating physical activity and functional training into their treatment.
Schizophrenia: Challenges in Treatment and Movement Disorders
Schizophrenia is characterized by psychosis, including delusions, hallucinations, and disorganized thinking. Patients with schizophrenia may exhibit positive symptoms like hallucinations and negative symptoms like emotional flatness or social withdrawal. Treatment often involves second-generation antipsychotics, which are less likely to cause the severe side effects seen with older medications.
However, antipsychotic medications can still have significant side effects, including tardive dyskinesia (abnormal involuntary movements) and neuroleptic malignant syndrome (a life-threatening condition characterized by rigidity and fever). It is crucial for OTPs and PTs to recognize these side effects and adjust treatment plans accordingly.
Functional Movement Disorders: Rehabilitation Approaches
Functional movement disorders, historically referred to as conversion disorders, involve motor and sensory dysfunction without an identifiable physical cause. These disorders are often triggered by stressful life events or past trauma. Treatment focuses on normalizing movement patterns, building trust with the patient, and providing positive reinforcement.
A key aspect of treating functional movement disorders is creating a supportive environment that encourages recovery. Patients often benefit from removing assistive devices as soon as it is safe and participating in goal-setting exercises to foster engagement in their rehabilitation.
Take-Home Message
- Exercise
- Home-based
- Functional training
- Weights
- Walking
- Innovation
- Dance
- "Decode" the behavior
- Vigilance-Fall prevention
- Floor rise
- Environmental causes
- Hip protectors
- Caregiver training
Here is an example of dance.
Conclusion: Integrating OT and PT Interventions
Managing neuropsychiatric conditions requires a holistic approach integrating OT interventions with physical activity, mood, hygiene, and functional training. We must remain vigilant for signs of medical complications, such as medication side effects, and ensure that patients adhere to their treatment plans. Encouraging creative activities, such as dancing or pet therapy, can help engage patients in rehabilitation while promoting physical activity and improving their quality of life.
Incorporating evidence-based strategies and maintaining a patient-centered approach will ensure that we provide the best care for individuals with neuropsychiatric conditions, ultimately improving outcomes and reducing caregiver burden.
Exam Poll
1)Which condition is not associated with the triad of symptoms in normal pressure hydrocephalus (NPH)?
The key symptoms are gait deviation, cognitive impairment, and loss of bladder control. That is the traditional triad, while spasticity is not.
2)Which of the following is characterized by a step-down deterioration?
The correct answer is vascular dementia.
3)The patient with a bipolar condition who is taking Lamictal (Lamotrigine) should be monitored for what potentially serious side effect?
Rash would be the correct answer for this one.
4)Which of the following is a negative symptom of schizophrenia?
An inability to gain pleasure from activities is a negative symptom. Remember OT interventions can target that domain.
5)Which of the following would NOT be an intervention strategy when working with a patient with functional motor disorder?
You would not want to maintain an assistive device as long as possible. You want to try to get those removed to make the patient as safe and as assistive device-free as possible.
Thanks for your time and attention to this topic. I hope this helps in your practice. We will now move to your questions.
Questions and Answers
With Electroconvulsive Therapy (ECT), have you seen patients having trouble retaining new information?
Yes, I have seen challenges with retaining new information in some patients, especially those with chronic depression. However, this is not a universal outcome. The most common clinical issue is a temporary memory haziness right after the procedure. In some cases, I have observed difficulties with learning new, more complex skills post-ECT, but these instances are not the norm.
Can you define step-down progression with cognitive decline?
Step-down progression refers to the decline caused by a series of vascular events in the brain. These events might not always be visible on imaging. Typically, the patient functions well, and then there is a noticeable cognitive decline, such as disorientation or mild cognitive impairment. After a period of leveling off, there’s another noticeable drop—perhaps with more significant word-finding problems or issues recognizing people. This pattern of decline, followed by a plateau, continues as new vascular events occur, leading to a step down in cognitive function.
How can rehabilitation professionals help patients engage in physical activities that improve their well-being?
One approach is encouraging patients to engage in activities that bring them joy, such as dancing or walking dogs. These activities promote physical movement and provide emotional and psychological benefits. Focusing on what’s meaningful for the patient is essential, making rehabilitation an integrated part of their daily life and improving their quality of life.
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Citation
Klima, D. (2024). Rehabilitation strategies for persons with dementia and neuropsychiatric conditions: What's the evidence? PhysicalTherapy.com, Article 4928. Available at www.physicaltherapy.com
